[Discussion] Health Policies and ACA Reform/Repeal

The existing health thread is for discussion on how changes to current policy will/have personally affected you or those you know. This thread is for more general discussion of the subject.

They have dug their own grave, here.

Only in a world where people actually think about what they're being told.

In Trump's America, they'll increase the chocolate ration to 3.5 grams from 5 grams, and their voters will cheer.

To all those Trump supporters who voted to end "Obamacare" not realizing that their ACA enrollment WAS "Obamacare", to all those Trump supporters who sincerely thought that Mexico would pay for the wall, to all the Trump supporters who were serious about "draining the swamp", to all the Trump supporters who thought manufacturing jobs were coming back...

All I can picture is Ultron saying "You'll catch on".

The Congressional Budget Office and the Joint Committee on Taxation just released a report on the estimated costs of estimated the budgetary effects of H.R. 3762, the Restoring Americans’ Healthcare Freedom Reconciliation Act of 2015, which will repeal chunks of the ACA.

The report estimates that the number of uninsured would increase by 18 million in the first year. After the elimination of Medicaid eligibility and subsidies for insurance bought through the exchanges kicks in, that number would increase to 27 million and hit 32 million by 2026.

Premiums for individual policies bought through the exchanges (or directly from insurers) would increase 20 to 25 percent the first year. That increase would reach about 50 percent the year after Medicaid expansion and subsidies are eliminated. Health insurance premiums would about double by 2026.

Ryan has already come out and says those numbers are bunk because it does not take into account the replacement plan.

Well, where the fudge is this replacement plan at?

karmajay wrote:

Ryan has already come out and says those numbers are bunk because it does not take into account the replacement plan.

Well, where the fudge is this replacement plan at?

The CBO is already ahead of him.

Back in December they published several memos describing how they were going to deal with the inevitable repeal of Obamacare.

First, they established a clear definition of what they considered private health insurance:

Health insurance policies vary widely, ranging from some that offer substantial coverage for a variety of health care services to some with a limited scope or amount of coverage. Therefore, in preparing any estimate of the number of people covered by health insurance, it is useful and important to identify where to draw the line to distinguish policies that provide some type of comprehensive coverage from those that do not.

An important function of insurance is to provide financial protection against high-cost, low-probability events. Consistent with that notion, CBO broadly defines private health insurance coverage as a comprehensive major medical policy that, at a minimum, covers high-cost medical events and various services, including those provided by physicians and hospitals. The agency grounds its coverage estimates on that widely accepted definition, which encompasses most private health insurance plans offered in the group and nongroup markets. The definition excludes policies with limited insurance benefits (known as “mini-med” plans); “dread disease” policies that cover only specific diseases; supplemental plans that pay for medical expenses that another policy does not cover; fixed-dollar indemnity plans that pay a certain amount per day for illness or hospitalization; and single-service plans, such as dental-only or vision-only policies.

...

If the provisions of the ACA governing the definition of private insurance coverage were repealed, CBO would revert to the broader definition of private insurance coverage—a comprehensive major medical policy, as described above. Such a broad definition of private insurance coverage is in keeping with what the agency has used to estimate coverage in the past. For a discussion of how CBO would estimate coverage under alternative proposals, see CBO’s blog post about challenges in estimating health insurance coverage under proposals for refundable tax credits.

Then the agency acknowledged that any replacement plans coming out of the Republican-controlled Congress would likely be high cost/low benefit garbage so it isn't going to count people receiving tax credits for those plans as having health insurance coverage. They'll just be counted as receiving a tax credit.

In response to a future policy that had minimal federal or state regulations, CBO and JCT expect that some new insurance products would be offered that limited coverage to the amount of the tax credit. Some of those insurance products purchased by people using a tax credit would probably not offer much financial protection against high out-of-pocket costs. Depending on the size of the tax credit, however, the depth and extent of coverage and the premiums of plans could vary. As discussed in another blog post about how CBO defines and estimates coverage, CBO does not count plans that have very limited benefits in measuring the extent of private insurance coverage; in such an assessment, it counts only people with a comprehensive major medical policy as having private insurance.

Under such proposals, CBO and JCT would separately estimate the number of people who would receive the tax credits and, if policymakers expressed interest in such estimates, the number of people who would purchase private insurance in the nongroup market that met a broad definition of coverage. In that case, the latter estimate of the number of people with coverage would probably be smaller than the estimate of the number of people who would receive the tax credit.

If Trumps tactics have been any indication, you can now ignore any reports about decreasing coverage, increasing cost, and tanking the federal budget simply by saying it's a "politically motivated fake report" and a good chunk of your supporters will go right along with you. I'm not sure how people can combat this when actual, hard data no longer matters when making decisions about whether or not something will be bad for the people.

Between the amount of time that has passed since this conversation was dropped in the "Trump Administration" thread, and the fact that it's more on topic here, I am bringing over the relevant pieces to this thread to continue the conversation.

gore wrote:

There are many problems with the ACA. Probably its worst element is that it further enshrines the misguided notion of employer provided coverage. It also effectively guarantees profits for the useless middle men (private insurance companies) by law (it limits how much they can leach too, but it ensures that they can continue to do so indefinitely).

It's a plan bought by existing business interests, and while it improves access to coverage for some people it does so in a terribly inefficient manner.

More practically it doesn't actually improve anything for a majority of Americans. What most people see is simply an increase in their insurance costs with no personal upside. The people who are most likely to actually be helped by the ACA are also not a reliable voting block.

I think it's pretty easy to understand why it's hated.

Yonder wrote:

It objectively doesn't do that. People go to the exchange site and buy insurance regardless of whether they are employed, self-employed, or unemployed. Weakening the employer/health insurance bond was absolutely a part of the ACA. Just because it didn't eradicate it doesn't mean it strengthened it.

bekkilyn wrote:

True, because of he ACA, I was much more free to quit a very unhealthy job and move forward in a better direction. Now I'll likely have to decide between going back to that sort of misery or having no healthcare at all. I'll very likely end up choosing the latter despite the risk of losing everything I've worked for throughout my lifetime, not to mention life itself.

Now that doesn't mean that I'm completely thrilled with the ACA. Without all of the Republican obstruction, we would have all had something much better in place, and without having voted for Trump and an extremist GOP regime, we would have had the opportunity to improve the ACA and yes, perhaps even replace it with something much better in the future.

But now, we'll have nothing all over again unless we fight with every part of our beings to save what we have of the ACA despite its flaws.

gore wrote:

What? This is totally backwards. Employers over a certain size were required to provide coverage by the ACA. It's designed to reinforce this system.

So you can opt to buy expensive private coverage on the exchange? Guess what, you already could have bought private insurance before the ACA! The preexisting condition mandate helps between jobs, but the fundamental concept is that employers will continue to provide coverage.

Where did you get the notion that the ACA intended to change this?

Stengah wrote:

It was designed primarily to help people whose employer wasn't required to provide health insurance, or who worked for themselves. Reinforcing employer provided coverage was a move to mollify opponents (most of whom mainly opposed who it was coming from, not what it was doing, so it didn't work so well) and not have to send everyone to the exchanges at once. I think the plan was that once the uninsured and under-insured were taken care of and the costs started to get wrangled down to sensible levels, they'd start untangling the mess that is employer provided insurance.
Pre-ACA there was no financial assistance or tax rebates if you had to provide your own insurance. Having them in place now makes people less likely to feel they need to work a job they hate just to have health insurance.

Quintin_Stone wrote:

https://en.wikipedia.org/wiki/Patien...

Businesses that employ 50 or more people but do not offer health insurance to their full-time employees pay a tax penalty if the government has subsidized a full-time employee's healthcare through tax deductions or other means. This is commonly known as the employer mandate. This provision was included to encourage employers to continue providing insurance once the exchanges began operating. Approximately 44% of the population was covered directly or indirectly through an employer.

The entire employer-provided insurance concept is poison. It grew out of salary caps implemented during WW2 and should have ended with the war. And while the ACA does have an employer insurance mandate, we can't ignore state-level laws that require it, or the tax-breaks that are what really keep it alive.

Even though I support single-payer, I'd be sympathetic to a free market argument. But no free market for healthcare exists in the US.

gore wrote:

So you can opt to buy expensive private coverage on the exchange? Guess what, you already could have bought private insurance before the ACA! The preexisting condition mandate helps between jobs, but the fundamental concept is that employers will continue to provide coverage.

Post-ACA the private health insurance options are much, much cheaper. My State marketplace actually has cheaper and better plans now than my company provides, which would have been unthinkable ten years ago. In addition to the price decrease that comes from many of the ACA provisions (I assume the most important being just the scope of one price for an entire State that is locked in) the subsidies on top of that are tremendously helpful in making these options more affordable to poorer Americans, in addition to being objectively cheaper.

While the ACA did add an employer mandate, that mandate could easily be removed, because architecturally it's a very tiny part of the plan, compared to the entire state exchange framework and the other provisions.

Additionally, my understanding is that the Employer Mandate existed in a different form within the ACA, and the ACA just inherited it. Unfortunately my google-fu wasn't strong enough to verify this, even with various searches I only ever found references to the Employer Mandate from ACA, not legislation before that. At the very least many States had similar rules. I know that my Grandfather owned a business that he studiously kept under... some number of employees... so that he wouldn't cross the threshold that then had to worry about these things, including Healthcare. That was in California though, and it's quite probably that California had employer healthcare regulations above the National ones.

Can anyone verify whether or not some form of this regulation did indeed exist before the ACA?

Yonder wrote:

Can anyone verify whether or not some form of this regulation did indeed exist before the ACA?

It did not at the national level, which is one reason it was controversial. Before the ACA, the primary federal tool reinforcing employer-provided health insurance was tax incentives, and there was also a spotty patchwork of state-level mandate laws with various levels of enforcement.

OG_slinger wrote:
Yonder wrote:

If the ACA standard is sufficient then why was there Democrat pushback to letting the Exchanges reach across States?

Because insurance companies are largely regulated by state agencies and selling an insurance plan from one state to a consumer in another state means that the consumer's state regulatory agency would have to then allocate resources to provide oversight of other state's insurance company, which would lead to clashes and confusion between the two regulatory bodies. And none of that would protect the consumer.

Also, the ACA lets insurance companies sell across state lines. Doing so is so complex that no insurance companies have done so.

Honestly (and chiming in for myself, but as someone who works in a small subsidiary of a major non-health insurance carrier), the state approvals process for every insurance document, form, policy endorsement, etc., are generally seen as a huge pain in the butt, and one that can take months in some states even if there aren't any objections from regulators. Having that state-level oversight means that expanding offerings into a new state is a big process. I was personally hoping that the ACA would have lead to a change in that format; there have been some federal structural moves along with it, such as the Federal Insurance Office.

50 separate rules and process regimes is always going to be less efficient than one, and as alluded to above even when some regulations are made national, it's complex enough to prevent cross-state markets where they did not already exist.

It's very important to note that the situation with state-level regulation is not accidental. The various health insurance companies that have oligopolized the different states jealously guard their territories.

Republicans lawmakers have presented one of their replacement plans for the ACA and they've clear taken a page from Trump. They have the best plan possible. Their plan is to have other people make plans.

Spoiler:

I wish I was joking. I'm not.

Wait. Wait. Wait. They want to give people more choice. They don't want a mandate. Mandates are bad. So what that guy just said was that one way they'll enroll more people is to automatically enroll you if you're eligible for a subsidy. So telling someone "enroll or you'll have X penalty" is bad, but just enrolling them automatically is super good? I'm confused. I'm not necessarily against automatically enrolling people (assuming the thing they're enrolled in is good, they can change the plan, and the they don't also get hit with an automatic bill), but the logic is super confusing.

However, if it's cool to auto enroll people in health insurance if they're eligible, then we can extend that and say that people should be automatically registered to vote if they're eligible, right?

Also, on the "states can keep Obamacare if they want" thing: does that mean an Obamacare as it exists right now, or a defunded version of Obamacare? And how do they think the decreased size of the risk pool will affect premiums of the states that choose to stay?

Tkyl wrote:

Republicans lawmakers have presented one of their replacement plans for the ACA and they've clear taken a page from Trump. They have the best plan possible. Their plan is to have other people make plans.

Spoiler:

I wish I was joking. I'm not.

Collins said. "But if we do not start putting specific legislation on the table that can be debated, refined, amended and enacted, then we will fail the American people."

"Of course, we've been failing the American people on this front for well over 8 years, so continuing that streak isn't entirely off the table, but some of my aides have been saying that that may look bad now that we own both houses and the White House, so a couple of us are thinking about taking a crack at this."

Aetius wrote:

It's very important to note that the situation with state-level regulation is not accidental. The various health insurance companies that have oligopolized the different states jealously guard their territories.

I don't think that was the source of this, though. They are taking (smart) advantage of a political philosophy which says that state control should be the default for the US, and which has strong adherents in at least one of the parties. That's been around more than a century before health insurance even existed...

They need to get it right. Obamacare without the individual mandate and a *large* percentage of eligible people participating nationally is *fiscally* dead in the water. It simply will not work. And the primary way to reduce the number of people participating is to allow states to opt out.

I don't know what they are thinking of, although being able to avoid the coming fecal storm front by saying "We tried to fix it, it was those other bozos who screwed you!" comes to mind.

We are in the first months of an 8 year run towards single payer healthcare in the US.

Robear wrote:

They need to get it right. Obamacare without the individual mandate and a *large* percentage of eligible people participating nationally is *fiscally* dead in the water. It simply will not work. And the primary way to reduce the number of people participating is to allow states to opt out.

I don't know what they are thinking of, although being able to avoid the coming fecal storm front by saying "We tried to fix it, it was those other bozos who screwed you!" comes to mind.

We are in the first months of an 8 year run towards single payer healthcare in the US.

I really hope you're right because (at least long-term) all this mess we're going through and will be going through would have a lot of value. While I didn't want the "burn it all down" to happen, now that it *is* happening, I do want it to ultimately result in positive things.

I'm not at all opposed to strong state rights because in some cases they can protect against an oppressive federal government (kind of like California may be doing now), but I also believe there are things that do need to function on a federal level and healthcare is probably one of those things because it sucks living in a state where healthcare is considered a privilege for the wealthy rather than a right for all.

Robear wrote:

We are in the first months of an 8 year run towards single payer healthcare in the US.

We're in the first months of an 8 year run of systematically dismantling what little social safety net our country has.

We won't have single-payer healthcare. We'll be lucky if we see Medicare and Medicaid cut to hell, vouchered, and block-granted.

My biggest problem with the idea of "the liberal States can keep Obamacare if they want, while the rest will do... whatever the f*ck we're eventually going to maybe think about deciding on" is my total lack of faith that six months later the GOP won't gut the funding for the Obamacare option the liberal States kept while going "neener neener neener, we told you Obamacare is awful, look at all those liberals dying from treatable issues".

OG_slinger wrote:
Robear wrote:

We are in the first months of an 8 year run towards single payer healthcare in the US.

We're in the first months of an 8 year run of systematically dismantling what little social safety net our country has.

I think that's what he meant. 8 years of the solutions and stopgaps holding us back from the brink being eviscerated, followed by rock bottom and then the US finally choosing single payer.

Yonder wrote:
OG_slinger wrote:
Robear wrote:

We are in the first months of an 8 year run towards single payer healthcare in the US.

We're in the first months of an 8 year run of systematically dismantling what little social safety net our country has.

I think that's what he meant. 8 years of the solutions and stopgaps holding us back from the brink being eviscerated, followed by rock bottom and then the US finally choosing single payer.

Yep, the question is no longer whether or not we'll reach rock bottom because it seems almost inevitable now that we will, but instead what we are going to do about it when we get there.

I'm not quite as pessimistic as all that. I think that the Republicans are going to think that they are unlikely to escape accountability for what they do with health care, and will be forced to moderate their actual position from the rhetoric they've been able to freely spew before.

I am expecting a healthcare plan that is only a little different from the ACA, and not that much worse, if indeed it isn't actually better. They will then act like it's an enormous overhaul completely casting away all of the malice and incompetence of Obama's plan, rather than minor tweaks that could and should have happened five years ago if the GOP legislators had appropriate amounts of maturity and integrity.

However I have unfortunately continuously misread the amount of nose chopping that the GOP is prepared to do to spite it's face, so my confidence in the estimation that they will course correct as much as a party in charge of Congress and the White House NEEDS to do isn't as high as I would like it to be.

Yonder wrote:

I think that's what he meant. 8 years of the solutions and stopgaps holding us back from the brink being eviscerated, followed by rock bottom and then the US finally choosing single payer.

Conservatives will never "choose" a single-payer healthcare system regardless of how much practical and financial sense it makes. It'll be government run and therefore bad.

Democrats will have to control both Houses and the White House and will have to jam it through like Obamacare. Except the conservative pushback and FUD will be several orders of magnitude larger.

Yeah, so far the healthcare debate seems to have gone.

Before Obama:
Dems: So, globally the places that do singlepayer heath care really seem to have better, cheaper health care, and our experience with Medicare has also been positive, lets do that.
GOP: We totally need these state exchanges, it will keep the competition of the private market in place, but will still increase the bargaining base for consumers.
Dems: Sure, that's a reasonable compromise.

During Obama:
GOP: Man Obamacare sucks. If they really wanted to fix healthcare they would have gone singlepayer, this was just corrupt democrats giving a gift to the insurance providers.
Dems: Damn you guys are just unbelievable.

After Obama:
????
Not holding out hope for the GOP sticking to their guns on single payer though. (And to be fair that was never something that got huge party support, but it seemed like all of the conservatives who actually stated what they wanted to replace Obamacare with mentioned single payer.

Chaz wrote:

Wait. Wait. Wait. They want to give people more choice. They don't want a mandate. Mandates are bad.

This is the part where you're confused. They don't want to give people more choice. They just want to be the ones doing the mandating - the ones in control. Remember how the mandate was implemented in Massachusetts by a Republican, and a very similar framework was proposed by the Republicans well before Obamacare became a thing?

Robear wrote:

Obamacare without the individual mandate and a *large* percentage of eligible people participating nationally is *fiscally* dead in the water. It simply will not work. And the primary way to reduce the number of people participating is to allow states to opt out.

Obamacare is already fiscally dead in the water - it always was. So is single-payer, and any system that's based on giving people what they want with no thought to how it is going to be paid for. It wouldn't shock me at all to see the Republicans pushing single-payer now that they are in control. It's not about doing what's right, or even fiscally feasible, it's about who controls the loot and who doles out the goodies to get votes.

Isn't saying that single payer can't be paid for in flagrant violation of the (dozens of?) examples of countries having a single payer system and paying for it?

Yonder wrote:

Isn't saying that single payer can't be paid for in flagrant violation of the (dozens of?) examples of countries having a single payer system and paying for it?

I think the modifier "any system that's based on giving people what they want with no thought to how it is going to be paid for." deals with that.

Single player can work but people can't just have what they want regardless of cost.

Aetius wrote:

It's not about doing what's right, or even fiscally feasible, it's about who controls the loot and who doles out the goodies to get votes.

I don't agree with you often but I agree 100%.

Yonder wrote:

Isn't saying that single payer can't be paid for in flagrant violation of the (dozens of?) examples of countries having a single payer system and paying for it?

Not at all. Most of those countries don't pay for it - they just keep going further and further into debt. In places where the debt runs out, like Greece, the system simply falls apart.

The first rule of economics - economics always wins. Always. You can vote and talk and scheme all you want, but eventually, economics will catch up with you. You can't get something for nothing forever.